Featured topic and speakers
In this episode of Moving Medicine, AMA CEO John Whyte, MD, MPH, talks with Abe Sutton, JD, director for the Center for Medicare and Medicaid Innovation (CMMI) and deputy administrator for CMS, about the potential benefits and challenges of a new CMS payment model called ASPIRE, designed to transform how high-risk and rising-risk children are supported within Medicaid. Find out what this means for pediatricians, subspecialists and patient families. Learn more at CMS.gov.
Speakers
- John Whyte, MD, MPH, CEO and executive vice president, American Medical Association
- Abe Sutton, JD, director, Center for Medicare and Medicaid Innovation (CMMI); deputy administrator, Centers for Medicare & Medicaid Services (CMS)
Transcript
Sutton: There's a clear focus placed on the pediatric population, in particular, the pediatric population with chronic disease. How can we delay disease progression? How can we help support these families?
Dr. Whyte: Welcome to Moving Medicine, a podcast from the American Medical Association where we explore the policies, innovations and opportunities transforming health today. I'm Dr. John Whyte, the CEO of the AMA. Today we turn our attention to pediatric care and a bold new effort to transform how high-risk and rising-risk children are supported within Medicaid.
Joining me is Abe Sutton, director of the Center for Medicare and Medicaid Innovation, CMMI, and deputy administrator for CMS. He's here to shed light on how a new model is redefining priorities, payment and accountability for pediatricians and subspecialists while challenging states to embrace a new standard of care. Abe, welcome.
Sutton: Thank you for having me on.
Dr. Whyte: Well, pediatric populations are certainly a very important population to talk about. And I'd love to hear more about this model and why you chose this population.
Sutton: For us, launching ASPIRE really started with the patients that we were thinking of and their families. When I think about the care journey that one of these families go on, the word that comes to mind is fragmentation. The team put in front of me a picture that was drawn by the mother of a six-year-old who has multiple chronic conditions. And she was trying to lay out the struggle with coordinating all aspects of her child's care.
She had the school services, the social worker there. She had the medical doctors that had to be seen. She had therapists on the outside that had to be seen. There were subspecialists that had to be seen. There's the coordination of all this. There's transportation so that this child could get to every appointment that they have to get at. And in the end, there's dozens of nodes in this picture of different endpoints who are trying to give care, and no one at the center with this family trying to help them navigate the system.
Our goal in ASPIRE is to give a coordinated approach for the 23% of Medicaid children with high and rising risk, so that their families are not flying blind in the system. They're not trying to sketch out and keep track of it. And what they're instead doing is going through a system where somebody is holding their hand and guiding them through it.
Dr. Whyte: Well, what were you seeing, Abe, that inspired you when you were thinking about models at CMMI?
Sutton: So, our mandate includes both Medicare and Medicaid. And under the leadership of Secretary Kennedy, there's a clear focus placed on the pediatric population, in particular, the pediatric population with chronic disease. How can we delay disease progression? How can we help support these families? That was something that we turned to, based off his focus on chronic disease management in the pediatric population.
And in designing this model, what we were looking to do was accelerate state pediatric innovation readiness and effectiveness. So what ASPIRE really does is give states more tools to empower pediatricians to support patients.
Dr. Whyte: Well, it starts with definition and criteria. And that's always important. So we have high risk. And I think most of us probably could agree what those criteria are. But you also have rising risk, which is somewhat subjective. So talk to us about these definitions.
Sutton: So there are patients with different medical conditions included in here. There's also different behavioral conditions. When I think about children with autism, that's included in this scope. The interaction between these categories are high. An example that emerged for me is I was looking through, really, the decision around what to include here, is when we pulled up the percentage of kids with autism who also had asthma. I'm like, oh, why should that be? But there's a degree of correlation that we see emerge in the data.
So by looking at this rising risk category, we're getting out the prevention. We're getting at the slightly upstream version of this to say how can we prevent that? And let's set up the right tools, the right information, to delay disease progression.
Dr. Whyte: And what are those tools?
Sutton: So, there are a couple of supports that are important to have in place here. One is that care coordination piece, the thing that really we anchored in early in the journey of exploring the pediatric space. So that could take the form of a social worker, someone to help navigate this system, find the right supports, help ensure you're getting the engagement from the physicians that you're seeing.
The pediatrician, obviously, plays a massive role. But their practice may or may not be staffed to support this, and they may not be reimbursed in Medicaid today for doing that.
Dr. Whyte: And care coordination is difficult for any patient, let alone a child who often has to coordinate with a work schedule of a parent, transportation issues and all. Is it much harder for Medicaid population for care coordination?
Sutton: I think it's hard to navigate when you don't feel like you're in control of your care journey and you feel lost when your child is experiencing this. And so, I think you've intuited something hard, that it is really hard on a Medicaid beneficiary. Some people may have an additional challenge with—maybe they don't have a car and that could be an additional barrier. There's financial aspects in who's eligible for Medicaid, so that could play a role. Many of these children are also eligible—depending on the state—for Medicaid due to their condition. And so there's some variation there where we're looking at a big chunk of this population.
In addition to the care coordination piece, I think it's important that there be an aligned incentive piece, that there be a structure that goes beyond that to say, OK, we're going to give you the right incentive structure to deliver that care proactively early on and look out for this patient population. And then we need to also make sure that there's information on how delivery of care changes outcomes, on how it impacts the cost of care for the patient.
And doing this could really set up the right incentive where you have the ability to act, and the information you need to act, and are paid for the activity you need to deliver to change outcomes.
Dr. Whyte: Tell us a little more about how that incentive structure will work.
Sutton: So, we've drawn on the approach used of accountable care organizations and are using them now in Medicaid to support patients. And so, I would envision a pediatrician coming forward, pediatric practice, and saying, all right, we want to deliver care for the patients that we care for in a different way. Let's take on this accountability for spend. Let's be tracked on the core quality outcomes that matter. Give me the information. Give me advanced cash flow so I can support this. And over time, I'm willing to take on accountability for the cost outcomes.
Dr. Whyte: What about folks that are skeptical? We've had ACOs for a while. Sometimes they worked, sometimes they haven't. How is this different? Because I have to evaluate participation in it.
Sutton: So this is set up for the pediatric population. So it's ACOs to care for kids with chronic disease. And there are examples—in different states—of experimentation in this form. There's a lot of success to draw on from the Medicare space with ACOs. But CMS coming forward to say let's get a couple of states that we'll partner with to support pediatricians or managed care entities in the support for those patients, that's what's new here.
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And that's where we're looking to say, if you want to step in and give more supports to your patients, let's think creatively together on what that should be. And we'll work with the state to find the right structure that works for them, so that they could support the patients that they want to support in Medicaid with high and rising risk.
What's important to us is that there be financial rewards to incentivize this activity, this coordination, the transmittal of data, so that families have more support. This should include things like 24/7 access to somebody who could answer your questions. A lot of the spend on this population is because you panic at 11:00 PM at night when your kid is crying, when something is happening and you don't know the answer, and you're left desperate with no one to turn to.
Dr. Whyte: Well, every does that independent of whether or not you're covered by Medicaid.
Sutton: But imagine if your kid has a number of chronic conditions. It's more stressful. It's more challenging. Well, let's give that family somebody that they could call who's got medical training and can answer their questions 24/7.
Dr. Whyte: OK.
Sutton: In a normal reimbursement structure, it typically is challenging to do so.
Dr. Whyte: Why? Why?
Sutton: I mean, I've been on hold on Sundays when my daughter has whatever the particular thing is and I'm panicking. And then you don't want the answer to be let's go to the emergency room. Because for these families, this happens more often. And they will go to the emergency room many times. And so, the reason why it's more important to give these families access 24/7 is this will happen a lot, and it makes sense to give them that support.
Dr. Whyte: Well, then, one could argue there's lots of frameworks that CMMI could utilize, but you've chosen accountability framework. Why?
Sutton: We think it's important to set up an incentive structure where you make the right decision to give this tool and that tool and that tool. And we have many that we're requiring here, right? The 24/7 access, the idea that there has to be a care coordinator. It doesn't have to be a social worker. We give you flexibility on that, core elements. And then over time, that it does move into accountability for what you drive. Because we've seen that work.
Downside risk in Medicare has been effective. And in Medicaid, we want to experiment with supports for the pediatric population built off of that structure. Because for too long, we've neglected intervening in this population in a way that we need to. And Secretary Kennedy has shined a light on the need to manage chronic conditions and delay their progression in the pediatric population. And it's overdue that we focus in and have an approach here.
Dr. Whyte: But this is a new perspective for many providers and systems to move to this value-based care approach in these high-risk and rising-risk populations. So what support are they going to have if you want them to transition to this type of model? Because let's be fair, people may be skeptical. There's some uncertainty. There's financial risk. And people are loathe to do things for which they're concerned for financial risk. So how do we—
Dr. Whyte: Let's assess that.
Sutton: That's fair. So number one is there's a glide path. You're not taking on financial risk at the beginning of this journey.
Dr. Whyte: Explain that to folks.
Sutton: So we're looking at a multiyear model. First, we're going to partner with a state that chooses to apply or multiple states that choose to apply. And we'll set up a structure where they're building up infrastructure, building blocks, to support pediatricians or managed care entities. They come in and then at first, they might just be paid for the activity that they do. And then over time, it transitions to accountability for cost. This will be something we'll work on the right approach with that state for how that glide path is structured.
In addition to that, we will be sharing data and tools to help manage the population, to help support in this journey. It's a different way of practicing. It's the right way of practicing. You're able to give more supports to your patients. But we need to help ensure that pediatricians are empowered.
Dr. Whyte: Is it the right way to practice, or is it the right way to pay?
Sutton: So what this structure sets up is something that enables you to practice in the right way. It's not people in Washington determining you should deliver this service or that service. And instead, what it is us identifying core things that we know make a difference, giving you flexibility in how to do them, and then stepping back and saying, "What other wraparounds do you need? That's up to you."
Dr. Whyte: Well, it's incentives and disincentives that impact how physicians provide care, as well as how patients consume care, too. So there's multiple factors at play here. But as we think about what does success mean, it's those outcomes. How are you choosing what outcomes define success for these populations?
Sutton: Primarily here, we really were motivated by the experience of families in a system that they feel like they're blind when they walk through today. Do they feel like they have to turn to the emergency room because there's nowhere else for them to go? Or, do they feel like they know what to do? Do they feel like they have someone guiding them through the system?
And then when I look at the children that we're trying to impact, what are the life outcomes that they will have over time? Are we setting them up on a better trajectory than they would have been on in the absence of ASPIRE? If so, ASPIRE has been successful beyond our wildest dreams.
Dr. Whyte: Now, will there be time for states to prepare in advance?
Sutton: 100%. We're committed to partnering with states that choose to apply and be in ASPIRE to structure the right approach that's customized for their state and their population, and then have a multi-year implementation period and then launch the model to transform delivery.
I realize that's a lot. It's a long lead time. We often do have long lead times when we're doing models on Medicaid because each state needs a customized approach. And I think that's appropriate. But I think the payoff will be there. I think the improvements in quality that we'll see for these children, the transformation of their life trajectory, will be meaningful.
Dr. Whyte: What's the quality measures? Is it decreased hospitalization? Is it decreased comorbidities? Is it decreased use of the ER? Is it decreased spend? What are we talking about here?
Sutton: So spend, primarily, I'd put it in a cost measure. But when I think about delays in disease progression or when I think about certain comorbidities being managed, that would define success. But I also think a core metric of success here is the family's experience. And I keep going back to that, because that really was our motivator in designing ASPIRE. Because we're truly looking to have a transformation in the experience that families of children with high and rising risk have when they interact with the health care system.
Dr. Whyte: So you started off with a patient care journey and the problems that definitely exist, particularly for high-risk and rising-risk patients, children, in the Medicaid population. So let's end with, why is this model better for the patient care journey?
Sutton: It goes back to incentives. And ASPIRE sets up the right incentives. Through ASPIRE, states are going to be able to support pediatricians and give them a way to deliver care for patients who need more proactive engagement and families who need more support to navigate our health care system in a way that they just cannot today.
The economics of pediatric medicine are really challenging. And giving a structure where you have that social worker doing the care coordination, where you're able to give 24/7 access to somebody with clinical training, can make a difference for these families and for many patients who are struggling to navigate the system. Those are the missing elements.
And so I do think the care journey looks different because you engage proactively with the right care in a setting that might be less intense than you'll need to if you first confront this three years from now because it was just hard to get an appointment, or because it was just hard to get in or because you couldn't get there because transportation was hard to book.
Dr. Whyte: Are there elements unique, though, to this population? Because I could say many of those elements that we've talked about, trying to get an appointment, trying to get access to someone, that's for all of us who are parents and have kids. What's unique about this model that benefits this particular population?
Sutton: I would think of this model as combining all the challenges that you're describing for many of us as parents, and putting them all at once with so many different types of entities to coordinate with. You have to deal with the school counselor. You have to deal with the outside therapists that you're seeing. You have to deal with the subspecialists who's treating your child's condition. In addition to that, you might need to go for occupational therapy. And then you need to go out and have the normal pediatrician that you see.
And none of these folks are talking to one another. For the average parent, there is obviously a degree of challenge in navigating the health care system. But when I just think about what these families experience when there's so much to coordinate, when there's so much more of this and it stacks up, it's just hard to do that while working a job, while coordinating with your kids' school schedule. And it just gets harder and harder.
Dr. Whyte: Do you predict that this will decrease costs to the system?
Sutton: I don't know. I think that this will enable us to spend more effectively. This will not increase costs, that's our mandate. We can't do anything to increase costs. But I think what this will do is transform the experience of families as they interact with the health care system.
Dr. Whyte: How do you ensure that it does not decrease quality of care?
Sutton: So, I don't see any way that more support and coordination could decrease quality of care, more access. But what we do set up is a rigorous evaluation approach where we look at data, evaluate it, share it with the public.
Dr. Whyte: Continuous over time?
Sutton: Continuous over time. Year by year we put out evaluation reports, and we'll be doing that on ASPIRE.
Dr. Whyte: Well, Abe, thanks for joining me today. Where can states find more information?
Sutton: So, states can find information on the CMS website where we'll have a web page on the ASPIRE model. I also will anticipate that many states will be hearing from me in the days ahead about the ASPIRE model and why I think it's something that they should consider. We have a robust outreach plan because we want to draw in states from across the country to come in and partner with us because we think this will make a real difference for the pediatric population with high and rising risks.
And so thank you for the opportunity to speak about this with the medical community, because I hope that they choose to engage in the states that choose to engage in ASPIRE.
Dr. Whyte: Well, thank you, Abe.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
